Approach toPleural Effusion

MED 341

Ahmed BaHammamProfessor of Medicine

Pulmonary Unit & Sleep Disorders CenterKSU

Up to 25 ml of pleural fluid is normally present in the pleural space, an amount not detectable on conventional chest radiographs.

Development of Pleural Effusion

pulmonary capillary pressure (CHF)

capillary permeability (Pneumonia)

intrapleural pressure (atelectasis)

plasma oncotic pressure (hypoalbuminemia)

pleural membrane permeability (malignancy)

lymphatic obstruction (malignancy)

diaphragmatic defect (hepatic hydrothorax)

thoracic duct rupture (chylothorax)

Pleural Effusion

Pleural effusion is an abnormal accumulation of fluid in the pleural space. The 5 major types of pleural effusion are: Transudate, Exudate, Empyema, Hemorrhagic pleural effusion or

hemothorax and Chylous or chyliform effusion.

Light. NEJM 2002; 346:1971Annual incidence in the US

Causes of Pleural Effusion

Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugs

Evaluation

History: Dyspnea Pleuritic chest pain Cough Fever Hemoptysis Wt. loss Trauma Hx. of cancer Cardiac surgery

Physical: Dullness to percussion Decreased breath sounds Absent tactile fremitus Other findings: ascites, JVP, peripheral

edema, friction rub, unilateral leg swelling

Chest X-Ray

Lateral Decubitus

CT Scan

Indications for Thoracocentesis

Indications for Thoracentesis

Likely indicated in most patients > 1 cm layering on lateral decubitus

No need for thoracentesis for patient with obvious cause may not need further study (CHF with bilateral effusions. However: In heart failure: febrile/pleuritic pain,

unilateral, no cardiomegaly, no response to diuresis

Pleural fluid analysis

Bloody: Hct <1% not significant 1-20%= CA, PE, Trauma >50% serum Hct = hemothorax

Cloudy trig level >110mg/dl = chylothorax

Putrid odor stain and culture = infection?

Light’s Criteria

Pleural fluid is exudate if one or more: Pleural LDH/Serum LDH > 0.6* -OR- Pleural protein/Serum protein > 0.5 -

OR- Pleural LDH > 2/3 upper limit of normal

(serum) Usually > 200 IU

Absence of ALL: transudate Sensitivity 99%, Specificity 98%

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

Transudate

•CHF

•Cirrhosis

•Nephrotic syndrome

Exudate

Pneumonia

Malignancy

Pulmonary Embolism

Exudative Effusion

Cell count - Neutrophil predom acute pleural process (pneumonia, PE)

- Lyphocytic predom chronic process (Cancer, TB, CABG)

Culture/stain- infected fluid Glucose- low level (<60mg/dl)

(pneumonia, CA) Cytology- malignancy (non-dx-

thoracoscopy) pH- parapneumonic <7.2 -must

drain fluid malignant < 7.2 –poor

prognosis

Malignant Effusions

Clinical features suggestive of malignacy:

Symptoms> 1mo, absence of fever, blood-tinged fluid, chest CT suggesting malignancy

Lung >breast > lymphoma/leukemia metastatic adenocarcinoma positive cytology 70% Lymphoma 25-50% Mesothelioma 10% Squamous Cell Carcinoma 20% Sarcoma within pleura 25% Pleural fluid: bloody, lymphocytic, decreased or normal

glucose and pH, cytology

EXUDATIVE EFFUSIONS

Lymphocytic (> 50%) CA (30-35%) TB (15-20%) Sarcoidosis

PMNs Empyema Parapneumonic Rheumatoid Pulmonary infarction

PMN or Lymphocytic PE Conn tissue disease Post-cardiac injury

Eosinophilic (> 10%) Trauma PTX CA Asbestos, parasites Pneumonia

RBC > 100,000/mm CA Trauma Pulmonary infarction

EXUDATIVE EFFUSIONS

Other Tests Suspected TB

Adenosine deaminase (> 50 IU/L)

B2 - microglobulin Lysozyme III (> 20mcg/mL) PCR (Sens 100%, Spec 95%) AFB (smear 10-20%; cx 25-

50%) PPD

Suspected Rheumatoid Pleural RF Low glucose

Suspected SLE Serum

Complement Pleural ANA LE cells prep?

Suspected Pneumonia pH

Suspected Pancreatitis Pleural Amylase

UNDIAGNOSED PLEURAL EFFUSIONS

15-20% of effusions Careful review of history, PE, meds,

risk factors Consider occult abdominal process Consider PE

UNDIAGNOSED PLEURAL EFFUSIONS

Cont’d Risk factors for TB or malignant effusion Weight loss > 4.5 kg (10 pounds) Fever > 38 C Positive PPD Large effusion (> 1/2 hemithorax) < 95% lymphs in pleural fluid

If ANY factor present, evaluate for TB, CA

UNDIAGNOSED PLEURAL EFFUSIONS

Cont’d PPD

If (+) and lymphocytic effusion, initiate TB treatment

If (-), repeat in 6-8 wks However, if effusion < 5% mesothelial

cells, consider TB treatment If (-), not anergic, > 5% mesothelial

cells, wait for repeat PPD in 6-8 wks If repeat PPD (-), not anergic and

cultures negative, observe

BEYOND THORACENTESIS

Pleural Biopsy Most helpful in evaluating for TB Limited utility for CA (40-50%

positive) Repeat cytology x 3

Sarcoid, fungal: might be helpful

Thoracoscopy Most helpful in evaluating for

malignancy

Approach to Pleural Effusion

PORCEL et al. AFP 2006; 73: 1212

Approach to Pleural Effusion

PORCEL et al. AFP 2006; 73: 1212

Approach to Pleural Effusion

PORCEL et al. AFP 2006; 73: 1212

Treatment

Thoracentesis – then treat underlying disease Uncomplicated pneumonia – antibiotics

Hemithorax involved/empyema – tube thoracostomy +/- VATS

Malignant effusion- chest tube +/- pleurodesis (sclerosants)VATS

Indications for Chest Tube

Empyema Complicated parapneumonic

effusion Hemothorax Malignant effusion- chest tube +/-

pleurodesis (sclerosants)

Pleural Biopsy

Most helpful in evaluating for TB

Limited utility for CA (40-50% positive)Repeat

cytology x 3 Sarcoid, fungal:

might be helpful

Thoracoscopy

You may find this lecture and notes

at this site:faculty.ksu.edu.sa/ahmedbahammam